Description:Soft tissue recession around teeth and implants is an epidemic problem in the field of dentistry. A predictable and long-term soft tissue augmentation outcome is primarily dependent on proper diagnosis, prognosis and treatment planning. Harvesting limitations of autogenous tissue from the palate represent a true challenge when treating patients with multiple recessions or gingival deformities around teeth and dental implants. The Advanced Platelet Rich Fibrin (APRF) and injectable platelet-rich fibrin (iPRF) are promising tissue promoters that can be a suitable alternative option.

Date Added:3/14/2018

Author(s):

Alina Krivitsky, DDSDr. Alina Krivitsky Aalam graduated with a BS in Dental Hygiene, DDS and a Certificate in Advanced Periodontics from the USC School of Dentistry. She is a Di...
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Alina, Thank you for the presentation. This presentation is not in my strong suit as to the number of and type of materials that can be obtained from a phlebotomy of a human vein. However, my research in graduated school was under the scrutiny of Dr. Charles Cobb in cellular biology. I have some questions and observations.
1. When slides are shown and you state that the is more volume of new biotype and more keratinized tissue is observed. I'm not sure that I agree that the biotype has changed because biotype is a genetic determination. I agree that the tissue volume is greater but biotype remains the same. In the same slides I see root coverage that is a combination of the marginal keratinized tissue that was coronally repositioned but I don't see and an increase in attached keratinized tissue or the zone of attached keratinized tissue. What I see is thicker tissue and root coverage which is our desired outcome but I don't think we can say that the APRF or IPRF in combination stimulated an increase in keratocytes because in my opinion without histology we cannot make those claims. I have had the some discussion with Pat Allen on his technique with alloderm. According to him it is not necessary to have keratinized attached gingiva on the superficial layer of the gingiva.
2. My objective in mucogingival surgery has been to first increase the zone of keratinized gingiva and in some cases to cover the exposed root surface based on the initial Miller Classification. What I think is interesting is that Danny Melker from Florida has always contended that a visible mucogingival recession is always associated with a underlying defect in the bone that is usually more "hidden" recession. In most of the cases you showed, the root of the teeth was in significant buccal version relative to the alveolar housing. Many of the cases I see the teeth were naturally in buccal version or were positioned there as a result of an orthodontic outcome.
3. The reason I bring this up is that I have seen many many of Danny Melker's connective tissue grafts from the palate and the tuberosity. He seems to be able always obtain a volume of autogenous tissue to graft multiple sites intra-oral. He uses no biologic modifiers or growth factors in his procedures. My observation on most of his cases is that the volume of the gingiva is thick and he is very good at obtaining root coverages. To my knowledge, he also has not show biopsy specimens.
The gold standard to determine the biology outcome and anatomical tissues is a biopsy or block section to observe the tissue at hand. Is there new attachment to the previously exposed root and what is or are the tissues that are attaching--bone, PDL, and new cementum or is there some form of epithelial attachment-short of long. Is there more keratination of the tissue and what percentage is attached to the bone or root or both. This may be a mute point when the root is covered but there is no way to scientifically claim what has occurred without the biopsy. I don't care is the tissue coverage was with autogenous, allograft, blood products, or just coronolly repositioned.
I hope my comments stimulate some thought and maybe more literature is available to support your conclusions that I am unaware of at this time.

Wonderful presentation and many thanks for accepting our invitation to speak at our Dentalxp-NYU Regenerative Summit this August. Any plans for long term follow up on these cases? Thanks again Dr. Salama

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